A client is experiencing sickle cell crisis precipitated by a right lower lobe pneumonia. The vital signs are: HR-110/min: RR-28; B/P-96/54: T-100.8 PO: Pulse Oximetry-96%. What is the best nursing action?

Maintain IV fluid infusion and assess adequacy of hydration

Provide continuous sedation for pain relief

Insert an indwelling (Foley) catheter and monitor hourly urinary output

Prepare for endotracheal intubation and ventilatory support

Answer and Explanation

The Correct Answer is A

A) Maintain IV fluid infusion and assess adequacy of hydration: This is the best nursing action as adequate hydration is crucial in managing sickle cell crisis. It helps to reduce blood viscosity and prevent further sickling of red blood cells, which is especially important in the context of pneumonia, as dehydration can exacerbate the crisis.

B) Provide continuous sedation for pain relief: While managing pain is essential, continuous sedation is not the most appropriate first step in this situation. Pain management should be addressed, but hydration and treating the underlying causes (like pneumonia) take priority.

C) Insert an indwelling (Foley) catheter and monitor hourly urinary output: While monitoring urinary output can be important, it is not the most immediate action in this case. Focus should be on hydration and addressing the sickle cell crisis rather than on urinary output at this time.

D) Prepare for endotracheal intubation and ventilatory support: Although respiratory distress is a concern with pneumonia, the current pulse oximetry reading of 96% indicates adequate oxygenation at this time. Preparing for intubation should not be the first action unless the patient shows signs of respiratory failure or severe distress.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is C

Explanation

A) Tinnitus: While tinnitus can be concerning, it is not a classic side effect of digoxin. It may indicate other issues such as hearing problems or medication interactions, but it does not typically warrant immediate communication with the healthcare provider in the context of digoxin use.

B) Constipation: Although constipation can occur in some patients taking digoxin, it is generally not considered a critical side effect that requires urgent attention. Patients are encouraged to manage this symptom through dietary changes or over-the-counter remedies unless it becomes severe.

C) Visual disturbances: Experiencing visual disturbances, such as seeing halos around lights or blurred vision, can be a sign of digoxin toxicity. Since these symptoms can indicate an elevated level of the drug in the bloodstream, it is crucial for the patient to contact their healthcare provider promptly to assess the situation and prevent further complications.

D) Vertigo: While vertigo can occur in various medical conditions and may be a side effect of other medications, it is not specifically linked to digoxin. If a patient experiences vertigo, they should monitor it but are not necessarily required to contact their healthcare provider immediately unless it is severe or persistent.

A. Remove the patch if a headache develops. B. Monitor weight on a daily basis. C. Place the patch on the anterior chest. D. Remove the patch as directed and inspect the skin.

Correct Answer is D

Explanation

A. Remove the patch if a headache develops: While headaches can be a side effect of clonidine, removing the patch is not the recommended immediate action without further assessment. The patient should be advised to consult with their healthcare provider if they experience significant side effects.

B. Monitor weight on a daily basis: While weight monitoring is important for some medications, it is not a specific recommendation for clonidine. Patients should be informed to monitor for signs of fluid retention or significant weight changes, but daily weight monitoring is not typically required.

C. Place the patch on the anterior chest: The clonidine patch should be placed on a hairless area of skin, typically on the upper arm or chest, but the anterior chest is not specific enough. Patients should be instructed to follow the manufacturer's guidelines for proper placement.

D. Remove the patch as directed and inspect the skin: This is the best discharge instruction. Patients should be informed to remove the patch according to the prescribed schedule and to inspect the skin for any irritation or allergic reactions. Regular skin checks are important to prevent any adverse reactions from prolonged patch use.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A client is experiencing sickle cell crisis precipitated by a right lower lobe pneumonia. The vital signs are: HR-110/min: RR-28; B/P-96/54: T-100.8 PO: Pulse Oximetry-96%. What is the best nursing action?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse should teach the client who is taking digoxin 0.125 mg PO daily to call the healthcare provider if which side effect is experienced?

Correct Answer is C

Explanation

A patient who has hypertension has been prescribed a clonidine patch. Which discharge instruction should the nurse provide?

Correct Answer is D

Explanation

The nurse auscultates a loud heart murmur while performing a cardiac assessment on a client. The nurse is aware that a heart murmur reflects:

When developing a plan of care for the client diagnosed with iron-deficiency anemia, the nurse would encourage intake of which foods?

Which statement, made by a client receiving pharmacologic therapy for hypertension, indicates a need for further clarification by the nurse?

The nurse administers the first dose of prazosin 1 mg PO to a client. Which nursing action is most appropriate following the administration of this medication?

In preparation for a client having a Schilling test the nurse should explain that the test:

The nurse is conducting dietary teaching for a client diagnosed with coronary artery disease. Which statement made by the client indicates an understanding of fat sources and the need to limit saturated fats?

The nurse auscultates a S4 heart sound during the morning assessment of a client. Which additional assessment data would correlate with this finding?